The National Institute of Medicine finally suggested that women obtain contraceptive care with full insurance coverage and without large co-pays. From one perspective, it was about time. Nearly half of all pregnancies are unintended and families should be expanded when there is true intent and not because contraception was not available. Also, since men have medications for erectile dysfunction covered by insurance, it's seemed only fair.

That stated, there might be a downside. Since no co-pays will be obtained, will the insurance companies increase payment to make up the difference (doubtful) or will the physician’s office loose the income in an already existing atmosphere of dwindling reimbursements (more likely)?

Will the frequency of unwanted pregnancies and abortions really fall? Even though condoms have been made available at some clinics for free, having the contraception easily available didn’t mean it was used at all or used correctly. When one provides something for free, is as appreciated as when one has to pay an amount, no matter how small, to increase personal responsibility?

When care becomes free or nearly free, there is almost always an increase in utilization. Is contraception one area of medicine that we would welcome increased utilization? Most, except the religions that do not believe in contraception, will agree this is ultimately a step in the right direction. Even so, there is no free lunch. Will insurance companies increase the premiums to pay for the office visits and the contraceptive medications and pass the costs to everyone else? We suspect the answer is probably yes.

At first glance, requiring insurance companies to pay for female contraception seems like a great idea but there is the issue of unintended consequences. Please share your thoughts on our Facebook pagewhere we've started the discussion. We’d love to hear from you!

Today, the good people of Mississippi will go to the polls to exercise their constitutional right to vote. One of the items they will cast their ballot on is Mississippi Ballot Initiative #26, which would give “personhood” to a fertilized egg. If enacted, this law will cause a chilling effect that will be felt throughout the infertility field as other states like Florida and Ohio, to name just two, gear up for similar referenda in 2012. The passage of Mississippi Initiative 26 will signal the start of a dangerous precedent, that if it gains momentum, will cause dire consequences for many of my patients.

This isn’t just about abortion, although this is what the proponents would like you to believe. Let me be clear, I don’t think the intention of the well-meaning individuals who may vote for this Initiative want to do harm. In fact, I am certain, people voting for the initiative probably feel they are saving lives. The problem is that Initiative 26’s proponents have not given the voters the right facts about the law’s devastating consequences in the state of Mississippi. The list of unintended consequences extends far and wide and involves women’s healthcare, the legal world and the infertile patient as well as the providers of their medical care.

Consequences to Women’s Healthcare

The following are very likely consequences of the passage of the amendment:

– The total outlawing of abortion, even in the cases of incest and rape.

– Outlawing of the vast majority of contraceptives including the IUD, the “morning-after pill” and Depo-Provera. Even hormonal contraceptives including oral contraceptives, patches and rings will thin the uterine lining preventing implantation. If interpreted as such, they will be outlawed. The only contraception that will probably remain will be condoms and we know how much men like to take a shower with a raincoat on….

– How can a physician surgically remove a tubal ectopic pregnancy thus terminating the life of an “embryo-person”? No, really, could someone tell me how a physician will be able to care for a patient with a life-threatening ectopic pregnancy?

– Are we really going back to the “good old days” when women were dying on a regular basis from botched backstreet abortions? Who will take care of the orphans?

Consequences to the Legal World

There are literally thousands of instances where the word “person” is written in the Mississippi statutes, each of which will have to be carefully reviewed to see how three-day old eight-cell stage embryos fit in. Think of the possible consequences:

– How will cryopreserved embryos inherit? Exactly what rights will they have?

– If embryos are created in Mississippi by a couple visiting from another state or another country, are they instantly going to be US citizens or citizens of the state of Mississippi?

– Will all embryos that do not survive have to undergo a burial? If they die unexpectedly, are they to undergo an autopsy?

– Women who smoke, drink in excess or use recreational drugs are at an increased risk for miscarriages. Are they to be charged with manslaughter or perhaps even murder if they are aware that their behavior could end the life of an “embryo-person”?

Disastrous Consequences to the Infertility Patient and Provider

It is clear that the proponents of initiative 26 feel the infertile patients are expendable. They don’t care that women and men’s lives and the families of Mississippi will be severely affected:

– Embryologists might be charged with manslaughter if embryos fail to survive in the laboratory.

– Will the laboratory even try to thaw frozen embryos understanding that at least 10-20% of them will not survive the thaw? Will the less expensive frozen embryo transfer procedures just disappear?

– If the physician transfers the embryos but the patient doesn’t conceive, will the physician be blamed? Will the doctor be accused of manslaughter for the failed implantation?

– Will frozen embryos be able to be moved outside of or into the state of Mississippi? Will Fedx take the chance of being accused of manslaughter should a transport tank fail in transit?

What will probably happen is that IVF will continue but physicians will only remove 2-3 eggs in a cycle. This will greatly increase the cost of the infertility treatment and result in much lower success rates. Those that can afford will go elsewhere. Who cares? For one, I do and I will bet every one of my patients will if Initiative 26 passes in Mississippi and they move on to other states, including Florida.

Well-Meaning Intentions With Unintended Consequences

This initiative is a really bad idea and has far more unintended consequences that I can even outline here in this short blog. The abortion decision is a personal decision between a woman, her partner, her conscience, her religion and her creator. We’ve been through this for years and years and the majority of Americans agree with this statement.

If Mississippians pass this law today, I know my work fighting the consequences of the Personhood Movement has just begun. Florida most likely will be one of the next states in their crosshairs. I will be forced to spend time, money and effort fighting these initiatives that I could otherwise devote to building families by encouraging the donation of unused embryos to patients in need. Instead of helping bring children into this world, I will be working diligently so I can prevent similar misguided political acts from destroying my patients’ dreams. Let’s hope the voters of Mississippi don’t find out too late that their actions have stymied the very goal they were trying to achieve – building loving families that would otherwise not exist.

I will admit that I was a bit overwhelmed with all that transpired recently on this blog.

My original goal to discuss the potential gender discrimination existing regarding the recommended ages for gamete donation was usurped into a rather emotional discussion on merits and evils of gamete donation itself. Some of the posts were so inflammatory that I have been advised by others to wipe out all the comments so as to do no harm to others that may eventually read them. For at least now, they will remain.

So many very complex issues were discussed simultaneously; some that were reasonable while others quite unreasonable and I was not even sure where to begin. To carefully start, I believe there are three perspectives that need to be better understood involving the gamete donor, the gamete recipient and the donor-conceived offspring.

The gamete donor’s perspective

Donors may donate for a host of reasons that may include monetary reimbursement, but nearly all will donate, at some level, so that individuals who might not otherwise raise a child can do so. Many donors will already have children or may have somehow been touched by infertility though a family member, friend, loved one, or even through media stories.

Some donate blood and/or their time and others donate their money. The difference with egg and sperm donation is that they involve individuals clearly giving a part of themselves. Do donors all understand the long-term effects of the donation? Perhaps some do, but not all. Do they wonder about the children their DNA helped to create? Perhaps, yes for some. Do they regret the donation? A vocal group will say “yes” but the many gamete donors who are content, at peace and even proud of their decision are silent in the wings, not feeling the need to make their past decision to donate known. Does that mean they are embarrassed by their past decision? Perhaps a few but I suspect most will simply state it was a private decision and not for others to judge or be involved in.

Was it wrong for them to have donated eggs or sperm as some might lead us to believe? I would emphatically answer “no.”

The gamete recipient’s perspective

Most patients who accept donated eggs and sperm do so reluctantly. Single women and same-sex couples may not have many options available to them and may enter the process more willingly. For the majority using donor gametes though, they are doing so because they or their partner are unable to use their own gametes to create and raise a child. Reluctance is the common denominator in their decision.

To simply state patients seeking donor eggs and/or sperm should adopt is naive. Many patients can’t adopt for a host of reasons including age, social situations, overall costs or personal medical history. Still, adoption is a viable option for some and infertile patients go through adoption all the time.

Others patients still want to experience pregnancy and birth. Is it selfish that they want this? I do not believe it is inherently selfish to want to experience something so basic in life as reproduction. It is a drive that goes to the core of all species. The reproductive process brings them and their partner (when they exist) closer in ways that are difficult to otherwise replicate. If one condemns reproduction using donated gametes as selfish, I suppose one should condemn all reproduction as basically selfish, especially when there are existing children who could be adopted. Many patients feel that reproduction comes close to an inalienable right that is not to be interrupted or disturbed by those who disagree.

Patients that reproduce using donated gametes are not “social parents,” as some would like us to believe while trying to diminish the importance of these parents. They are parents in every sense of the word. As I have written before, being a parent has to do with being there emotionally, physically and financially for future decades to come. Being a genetic parent may only take a few quick minutes of sexual activity. I will state the genetic contribution is important, but in the scheme of things, only a very small part of the creation of a child and a family.

DNA does not a family make – it is only part of the equation.

The donor-conceived offspring’s perspective

This is where the issues of gamete donation become so complex. As I have written before, I feel that my field has not paid enough attention to the perspectives of these individuals because they were never our patients. In fact, their very existence would not be was it not for our work bringing donors and recipients together. As a result, we have an inherent responsibility to donor-conceived offspring, having assisted in their creation.

Is it better that they never should have been conceived and born, eventually experiencing all that the world has to offer? I don’t see how that could ever be thought of as true. Inherent good is created when these special individuals grace our world.

Do they have a right to know their genetic background? Perhaps they do have a moralright to know, but this frequently comes into conflict with the right of privacy of the gamete donors and recipients. Would I want to know? I think the answer is “yes.” If I were a recipient of a donated gamete, be it eggs, sperm or both, would I want to be able to make the decision about telling my donor-conceived child? I also think the answer is “yes.” So, how can we possibly reconcile these potentially conflicting rights?

We need compassion, understanding and respect.

Compassion

We need to be better aware of how donor-conceived offspring feel. They will be curious about the donors. They will be interested in connecting with half-siblings, especially when they have no other siblings in the family in which they were raised. We need to consider how the donor-conceived offspring will tell their future or current partners about their genetic family. We need to understand that they will want to tell their own children about their ancestry.

Understanding

We need to better understand how disclosure will affect all parties involved. There is a great deal of angst and fear regarding disclosure with the recipients fearing most that their donor-conceived child or children will not love them anymore after they find out they were a product of gamete donation or after they connect with the gamete donor. We need to help move society and religion forward so donors and recipients will not be at risk for condemnation by friends, family or retaliation from their own religion. This will take a great deal of time and patience.

We need follow-up and well-designed research examining the effects of disclosure on all parties. Only by gathering information can we can share with donors, recipients and donor-conceived offspring the likely outcomes of disclosure and open-identity. We need to move from uncertainty to knowledge and from fear to hope.

Respect

There is a great deal of disrespect abounding on the topic of gamete donation and passions are running very high as was evident in the recent comments on my blog. The perspectives have almost become religious in character with extraordinarily narrow and unbending belief systems incapable of contemplating another viewpoint. Zealots want to indoctrinate all, bringing everyone to their own perspective, which they view as the only right one. We all need to take a step back and breathe. If we all realize that we are in this together, trying to do what is best dealing with all three perspectives, then we will work through our differences and come up with alternatives that will work best for the greatest number of people. We will never please the zealots but we can try to care for the greatest number possible.

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Possible solutions

I don’t pretend to have all the answers here and I’m not even sure I have asked the right questions yet. Having worked in this field for almost 23 years though, perhaps I have a perspective that could have some value.

Registry

A central registry, where information about donors, recipients and donor-conceived offspring could be stored, is an alluring concept but important practical issues abound. Who will pay for it, what information will be stored, who will have access to the data and will the information be truly secure are all questions that need to be answered before we undertake such a venture and before we put patients and families at risk. Understanding that we have already succeeded in collecting and reporting ART data though the CDC/SART, I do feel that we might be able to successfully build a data collection system for egg, sperm and embryo donation procedures. A multi-disciplinary discussion guided by the ASRM or a yet-to-be-formed special interest group is probably the best place to start working closely with our peers in other countries who have already initiated this process. I am concerned if we do not do this voluntarily, politicians who may have a meager understanding of the true issues will force it upon us.

Open identity

Creating gamete donation procedures with expanded open identity options would seem potentially to be the best of all worlds. It doesn’t mean that all donations must be open identity (i.e., it shouldn’t be mandated or legislated) for if we force this option on all, we take choice out of the hands of those involved and risk depletion of the gamete pools that are needed for so many.

I do not necessarily agree that open identity will be the answer for all of the problems but it could, most of all, benefit the donor-conceived offspring. Additional work must be done to also decide how and when the identity of the donor should be presented to the donor-conceived offspring. If we are creating an open gamete donation option for the children’s good, it is hard to argue that this information must not be released until they reach age 18 or 21. For the good of the child, having some sort of connection to the donor might indeed be best if initiated in the truly formative years and, certainly, before age 10.

Summary comments

Egg, sperm and embryo donation procedures are not inherently evil. They build families where they would otherwise not exist, an inherent good. We all need to better understand the three perspectives of donors, recipients and the donor-conceived offspring and, through compassion, knowledge and respect, work better together for the betterment of all the parties involved. This issue is a moving target and I beseech all those that feel so strongly on this topic to honor and listen to the opinions of others, understanding there is no right answer for everyone any more than there a single correct religion. I ask all to try to reign in all the emotion and focus this valuable energy towards discussion rather argument, compassion rather than condemnation, education rather than persuasion and respect rather than intolerance.

We have a long way to go but I feel we can get there together by understanding that each of us has much to learn from each other.

P.S. For those that would like to review a somewhat scholarly summary on disclosure in embryo donation from the perspective of the embryo donor, embryo recipient and the donor-conceived offspring, I encourage you to read one of my somewhat long, but comprehensive reviews on the topic by visiting my embryo donation blog by clicking here.

They discussed some of the outliers where egg donors were being offered up to 100K for their eggs. At NYU Fertility Center, they apparently offer 8K. Dr. Noyes acknowledged that the average reimbursement across the nation was probably closer to 4K.

As an alternative, she revealed that many women are beginning to cryopreserve (freeze) their own eggs, essentially becoming their own donors in the years ahead. a process that I think has great potential but should still be considered experimental, something that Dr. Noyes failed to mention.

I will admit, the country seems to be a little regulation happy. The answer to all things continues to be regulation in the minds of many.

Our lives are very complicated, I suspect more complicated than our parent's lives and their parent's before that. We humans continue to make our way through the maze of our lives feeling less and less in control. In times of turmoil, oil spills, a fractured economy, lost financial stability and the continual threat of terrorism, we seek stability and security. What better way to achieve this than through regulation? After all, regulation means that we don't have to even worry about that area any more and we can focus on the many other distractions in our lives.

In the real world, however, is the theme of unintended consequences. As we attempt to quell a leak in one part of the dam, another springs open thus relieving pressure. Regulation is almost always an uncontrolled experiment with the most wonderful of intentions. The problem is that it rarely achieves its lofty goals and almost always complicates the maze further.

The answer to high reimbursements to egg donors is to not offer them. The answer does not include limiting donor reimbursement as it will result in the harm of many recipients.

My field of medicine is the most regulated in all of medicine. In no other field do physicians have to display their success and failure rates for all to see. I have always wondered for those that demand this information, if they would be willing to place their professional lives out there for everyone to see. Oh, I must be confused. Regulation is for everyone else.

Don't regulate the number of embryos to transfer. Don't regulate reimbursement. Guide it all. Suggest strongly. Let the market take care of those that abuse the system. Let patients do the research and make the decisions. An odd concept which may not be entirely popular but one, I can only hope, my readers will at least contemplate.

In this world of unintended consequences, I tend to prefer to walk against the traffic that is coming for I know exactly where to look rather than strolling, when all supposedly is clear, only to be clipped by something originally unseen and unsuspected.